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Vpublic HEALTH REPORTS .V .OL~35 NOVEMBER 12, 1920 No vPUBLIC HEALTH REPORTS .V .OL~35 NOVEMBER 12, 1920 No. 46 A STUDY OF THE RELATION OF FAMILY INCOME AND OTHER ECONOMIC FACTORS TO PELLAGRA INCIDENCE IN SEVEN COTTON-MILL VILLAGES OF SOUTH CAROLINA IN 1916.1 By JOSEPH GOLDBERGER, Surgeon; G. A. WHzzLER, Passed Assistant Surgeon; and EDGAR SYDEI- STRICKEE, Statistician, United States Public Health Service. CONTENT& I. Review of literature. III. Fellagra incidence according to eco- II. Plan aid methods of present study. nomic status. Locality. Discussion. Population. (a) Bad hygiene and sanita- Pellagra incidence. tion. Season. (b) Difference in age and Dietary data. sex composition. Data relating to economic condi- (c) Differences in diet. tions. Differences in incidence Family income. among households. Availability of food supply. Differences in incidence Economic classification. among villages. Method of classification ac- IV. Discussion. cording to economic status. V. Summary and conclusions. Results of classification. VI. References. In the spring of 1916 we began a study of the relation of various factors to-pellagra incidence in certain representative textile-mill communiities of South Carolina. On a varying scale the study was continued through 1917 and 1918. The results of the first year's (1916) study with respect to diet,2 to age, sex, occupation, disabling sickness,3 and to sanitation4 have already been reported. At the present time we wish to record the results of the part of the study dealing with the relation of conditions of an economic nature to the incidence of the disease. L REVIEW OF LITERATURE. A close association of pellagra with poverty has been repeatedly remarked upon since the time of the first recognition of the disease. In the earliest account, Casal (1870, p. 93), discussing the diet of those 1 From Field Investigations of Pellagra. Submitted for publication Aug. 31,1920. 2 Goldberger, Wheeler, and Sydenstricker, 1918 and 1920a. I Goldberger, Wheeler, and Sydenstricker, 1920b; Sydenstricker, Wheeler, and Goldberger, 1919. 4 Goldberger, Wheeler, and Sydenstricker, 1920c. 15712-201--- (2673) Novemsber 12, 1920. 2674 persons attacked by the disease, remarks that "they eat meat very rarely since most pellagrins are poor field laborers, and this. circum- stance does not permit them -to eat meaat daily nor even from time to time." Continuing, he says: "Their only beverage is water. Their clothes, beds, habitations, etc., are strictly in keeping with their extreme poverty." Further along, discussing the treatment of-the disease, C-asal states that "milk, thanks to the butter it contains, is certainly capable of supplying the nutritive lack of the other foods; they iise it but rarely without having first removed the butter, since these poor people sell the butter in order that they may be able to buy other lnecessaries, thus using in their own diet what remains in the milk after having thus treated it." Much more definite and direct is Strambio (1796) who states that "thus much is certain, that pellagra is most at home where poverty and misery reign and increases as they increase." "Y. VTery interesting and significant is Marzari's observation.5 "I have several times observed," he states, "that if a villager falls into poverty, as happens so often as a result of a storm, droug1-or other calamity, pellagra does not fail to crown his misfortune and piut an end to his miserable existence." Holland (1820), in introducing his discussion of the cause and symptoms of pellaOr in a paper read in 1817, baed on observations of his own and on information secured from Italian physicians in the course of a journey to Italy, remarks: "The pellagra is a malady confined almost excIusively to the lower classes of the people; and chiefly to the peasants and those occupied in the Iabors of agriculture." He repeats this two or three times in other connections. In his dis- cussion of the etiology of the disease (p. 322) we find the following highly suggestive statements: "Though I have spoken of Lombardy as one of the most fertile portions of Europe, yet to those who con- sider the little certain relation between mere productiveness of soil and the prosperity or comforts of the population dwelling upon it, it will not appear very extraordinary that the peasants of this diss- trict should be subject to various physical privations unknown to the people of countries which are much less favored by nature. The fact unquestionably is, whatever be our speculations as to the cause, that the peasants of Lombardy do for the most part live in much wretchednless, both as regards the quantity and quality of their diet and the other various comforts of life. It further seems probable, if not certairn, that this evil has been progressively augmenting within the last 5 years; partly, perhaps, an effect of the wars which have so often devastated the country by marches and military contribu. tions; partly a consequence of the frequent changes of political state; together with the insecurity, the variable system of government, and 6 Cited by Russen, 1845, p. 167. 2675 Novesber 12,1l920.. the heavy taxes and imposts attending such changes. To these causes may be added a decaying-state of commerce and a faulty sys- tem of arrangement between landlords and the cultivators of the soil, all tending to depress agriculture and to reduce the peasanfy at large to a state of much misery and privation." Coxiing this dis- cussion, Holland remarks further (p. 333): "Animal food rarely forms a part of their diet, and although living on a soil which produces wine their poverty almost precludes the use of it, even when sickness and debility render it most needful. The same condition of poverty is evident in their clothing, in their habitations, and in the want of all the nor necessaries and comforts of life. The imniediate effect of these privations is obvious in the aspect of squalid wretchedness and emaciation which. forms so striking a spectacle at the present time throughout the greater part of Lombardy. I say particularly at the present time," because whatever may have been the progress of misery among the peasants of this country during the last half cen- tury it appears to have increased in a tenfold ratio during the last two years, the effect of bad harvests added to the preceding wars and political changes which have distressed this part of Italy." Hameau (1829), in the first recorded observations of pellagra-in France, reported that "this disease attacks individuals of both sexes and all ages, but I have not yet seen it in any but the poor and un- cleanly who subsist on coarse food." Lalesque (1846), in his account of pellagra of the Landes, cites a number of instances illustrating the conditions of misery under which pellagra occurred, finally oxclaiming (p. 421): "These are, the individuals attacked by pellagra, for it attaches itself to poverty as the shadow to the body." In a discussion of pellagra in Gorz-Gradisca, Berger (1890) very significantly observes: "The appearance during the last decennium of diseases-of the vine, the reduction in value of the product of the soil because of foreign competition, crop failures, increase in taxes, increasing living costs, all operated to undermine economic condi- tions, particularly of the poorer country folk, and thus prepared favorable conditions for the spread of the disease." Discussing the therapy and prophylaxis of pellagra in Bessarabia, V. Rosen (1894) bewails the attendant difficulties "in that, on the one hand, the alimentation with commeal porridge is a deeply rooted national custom, and, on the other, that the disease attacks the.poorest class of the population; 'N'am vaca, n'am lapte a casa' ('I have no cow and no milk in the house') is uniformly the reply of the patient to questions in relation to this subject," and Sofer (1909, p. 219), discussing the economic status of pellagrins (in Austria), remarks that "89.9 per cent haven't even a cow." Italics in o'rigal 26764 The xtremely unfavorable economic conditions of those subject to pellagrm (in Austria-Hungary, at least), is further strikingly sug- gested by the chaeacter of sowe of the recommendations for its con troL Thus Von Probizer (1899, p. 141) urged, as a necessar nmas- ure, "pecunry aid by the Government in view of the deplorable con- dition of the peasantry in the affected localities." V. Babes (1903), writing on pellagra in Roumania, remarks (p. 1187) taat "practically all pelagrins are very poor;" and goes into some detail in describing the unfavorable economic condition of the Roumanan peasant, which leaves him in debt to the landowner and the tax collector. In modern Spain we have Caarza (1870) remarlking (p. 66) that although he had seen cases in well-to-do individuals, the disease only exceptionally occurred mi those of this claw. He adds (ph 67) also that in his experience, unike the reported observations Qf others (Roussel, 1866, p. 431), pellagra is quite common in beggas. ' In dis- cussing the etiological rdle of widowhood, this keen observer expresses the opinion (p. 68) that this plays a part only in proportion as it tends to bring about a depression in economic well being and a con- sequent insufficient alimentation. Huertas (1903) describes the dis- ease as occUring amon the most miserable class of the population of Madrid, who live on the food picked from the city's garbage. In Egypt Sandwith (1903) found the disease highly prevalent among the poorer peasants of Lower Egypt. "In one viUage," he reports, "where the inhabitants are especially well to do because they get regular pay throughout the year from the Domains administra- tion, there were only 15 per cent of pellagrous men, while among the men of the village, which has the reputation of being the poorest, the percentage rose as high as 62." Gaumer (1910), discussing pellagra in Yucatan, states that the dis- ease did not become epidemic in that State until 1884, two years after a destructive invasion by locusts or grasshoppers.
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